Breast Cancer

Breast cancer is the most common cancer in women in the UK, affecting one in nine women at some point in their life.

What is breast cancer?

Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast. Damage to the DNA of these cells results in uncontrolled cell division and growth, and, eventually, sufficient cells accumulate to form a lump.

The cells invade normal surrounding breast tissue and can break off from the primary lump to spread in lymph channels or the blood stream to other organs where secondary lumps (metastases) may form.

The breast is divided into ducts and lobules. The most common form of breast cancer arises from the ducts and is known as invasive ductal carcinoma. Cancers arising from the lobules (invasive lobular carcinomas) are less common.

As with most cancers, the key to successful treatment is early diagnosis before the cancer has had the chance to spread to other organs.

What are the causes?

The exact causes of breast cancer have not been clearly identified, but certain risk factors have been identified:

• Getting older - 80 per cent of breast cancer cases are in postmenopausal women - it's relatively unusual in younger women
• Having a significant family history of breast cancer, which may be associated with inherited gene mutations (see below)
• Having no children or children late in life
• Starting your periods early or going through the menopause late
• Taking hormone replacement therapy (HRT) for a prolonged period
• Being overweight
• Drinking alcohol in excess

A genetic link

Fewer than one in 20 cases of breast cancer is inherited. About one person in 1,000 carries the genes responsible, so if a relative has breast cancer it's most likely to be by chance. However, you should be more wary if you have:

• A relative who was diagnosed under the age of 40
• A close relative with cancer in both breasts
• A male relative with breast cancer
• Two close relatives on the same side of the family diagnosed with breast cancer under 60 or with ovarian cancer
• Three close relatives diagnosed with breast or ovarian cancer at any age

It may be worth writing out a family health history record, to help you work out patterns of disease that run in the family.

If you’re worried, talk to your GP. You may want to think about genetic screening.

What are the symptoms?

Breast cancer may be diagnosed before any symptoms occur through screening. The NHS National Breast Screening Programme provides free screening for breast cancer for all women over the age of 50. If you're between 50 and 70 you should be routinely invited for a mammogram. Women over 70 are encouraged to make their own appointment.

Otherwise, breast cancer may be diagnosed when a woman develops symptoms that alert her to seek medical advice. All women should practise breast awareness. This involves getting to know what's normal for your breasts in terms of look and texture, so you can spot any changes and get them checked as soon as possible.

In particular you should look for:

• Lumps or thickening of the tissue
• Discharge from the nipple
• 'Tethering' of the skin, as if it's being pulled from the inside
• Any unusual appearance, sensation or pain

Remember, most lumps are harmless, especially if you’re young. But you should still get them checked by a doctor as soon as possible.

How's the diagnosis confirmed?

All patients suspected of having breast cancer must be seen by a hospital specialist within two weeks of an urgent referral by their GP.

Some hospitals run 'one-stop shops' for rapid assessment of breast lumps where all the examinations can be done on the spot, often with the results available on the same day.

To make an accurate diagnosis, doctors need to carry out a thorough examination. They’ll take a careful look at the lump itself, possibly using an ultrasound and mammogram.

They may take a sample of tissue using needle aspiration and/or needle biopsy. This is then analysed by a pathologist to assess whether malignant cells are present and confirm the diagnosis of cancer.

The cells may be tested to see if they carry certain receptors, which may influence the treatments offered. If they carry hormone receptors, it suggests they're sensitive to female sex hormones and hormone therapies are likely to be used in their treatment.

Cells carrying the Her2 receptor may respond to the drug trastuzumab (herceptin), which may be used in the treatment of some Her2 positive cancers.

Other investigations, such as blood tests, chest x-rays and CT scans, may also be done.
What's the treatment?

There's no quick cure for breast cancer - if anyone tries to tell you otherwise, be extremely sceptical. However, there are many effective treatments and the death rate from breast cancer in the UK has been falling for a number of years.

Once a diagnosis of breast cancer is confirmed, the exact treatment used, how soon it's given and how long it takes all depends on several factors, including:

• The stage of the tumour (how far it has spread) and whether there is secondary cancer
• The receptor status of the breast cancer
• The general fitness of the patient
• The menopausal status of the patient
• The woman's own wishes

Management of breast cancer is a team effort and a number of specialists may be involved including surgeons, oncologists and breast care nurses.

Treating early breast cancer

This is cancer where there is no detectable secondary cancer and it is confined to the area of the breast and possibly the nearby glands.

Neoadjuvant therapy

While surgery is usually recommended as the first treatment, sometimes hormone treatment or even chemotherapy may be offered before surgery. This is called neoadjuvant treatment.

Surgery

Surgery may remove just the lump with a surrounding rim of normal tissue (lumpectomy) or the entire breast may be removed (mastectomy).

Normally, surgery also entails some form of assessment of the underarm glands (axillary lymph nodes), which helps to guide further treatment. The glands may be completely removed (axillary node clearance) or just a few sampled.

Sentinal lymph node biopsy is a very selective but accurate method of assessing just one or two axillary nodes.

There's been a move away from very aggressive surgery. Just 20 years ago, radical mastectomies were widely performed. This operation left a marked depression in the shape of the chest, and women had to cope with feelings of being mutilated and scarred.

Now it's widely appreciated that such destructive surgery is often not necessary. For example, a lumpectomy combined with radiotherapy has been shown to be just as effective as mastectomy for tumours up to 5cm in diameter.

Postoperative recovery

How long you need to stay in hospital after breast surgery depends on your particular operation. Following mastectomy, it's often necessary to place a tube into the area of the wound to drain blood and fluid, improve healing, avoid bruising and reduce the risk of infection. This may need to stay in place for several days, but it may be possible for you to go home with the tube in place and have it removed by your district nurse.

After surgery, many women feel emotional and tired. Not only do they have to cope with the effects of a general anaesthetic and major surgery, but they also have to face many other issues, from living with a life-threatening condition to changes in their body image.

Plenty of rest and a healthy diet can help you get back on form, but it's also essential you address your psychological needs. Make the most of the support available. Most areas have trained breast care nurses, who'll be able to help with your worries and fears. Or you may prefer to find a local self-help group and talk to other women who've been through the same experiences.

Don't be afraid to ask any questions, no matter how trivial or silly they may seem to you. You may also like to give your partner and family a chance to find out more.

Possible complications

A number of women develop complications following breast surgery, including problems with wound healing and infection.

If you've had lymph nodes removed from your armpit, or if you've also had radiotherapy, you may experience:

• Damage to the nerves running through the area - this causes tingling, numbness or stiffness in your upper arm. It's usually temporary and may be improved with regular exercise. Ask to speak to a physiotherapist.
• Lymphoedema - this is swelling of the arm and hand due to interruption of the normal drainage of lymph fluid from the area. It may develop straight after surgery and resolve quickly, or appear slowly and be more long-lasting.

Prostheses

After a mastectomy, you may choose to wear a simple prosthesis to restore the shape of your breast. There are several different types available on the NHS. Your breast care nurse or doctor will be able to tell you more.

The charity Breast Cancer Care offers a free prosthesis fitting service, which is available throughout the UK. Trained staff offer information and advice on the range of prostheses and swimwear available.

Later, you may want to think about surgery to reconstruct the breast. Increasingly, women are being offered immediate reconstruction, with a new breast put in during the operation to remove the cancer. However, this can't be done in every case.

Living with a mastectomy

Getting back to normal life after a mastectomy may seem impossible at first, but it will happen eventually. Many women lose confidence and self-esteem. There are worries about the diagnosis, recurrence of the disease and long-term health.

Surgery for breast cancer may be traumatic and take months, or even years, to come to terms with. You may experience a turmoil of emotions, including grief, anger, sadness, isolation and anxiety. You may also feel unattractive, even if your partner is loving and understanding, and go off sex for a while.

Be patient. Try to talk through your feelings with someone (ask your GP to refer you to a counsellor) and ask your family to be patient too. Scars fade and the shape of your breast or chest may improve with time - if it doesn't, help is at hand.

Cancerbackup can put you in touch with a counsellor or local support group.

Reconstructive surgery

After any kind of mastectomy, you may want to consider reconstructive surgery to restore the look for your breast(s).

Techniques for breast reconstruction have improved greatly over the years, and it's now possible to restore many women's breasts to a reasonably normal look and feel, or at least to a state a woman feels happy with. It's not vanity, just getting back to normal.

The aim is to use the woman's own body tissues to build the new breast. While it may be necessary to use an artificial implant, muscle, fat and skin can be taken from the chest wall, abdomen or back.

It's impossible to restore the breast to how it was before. It will always be different - scarred for example, or with different sensations - but most women are happy with the results.

When is it done?

Some doctors prefer to do reconstructive surgery at the same time as the cancer surgery. while others want to wait a year or more, especially if the woman is also undergoing radiotherapy, to make sure the skin has recovered completely.

If you want reconstruction after surgery, it's important you speak to your surgeon about this before the initial operation, as it could affect the way the operation is done.

It's also important to note any surgery carries risk. In addition to other problems, breast reconstruction can result in pain, scarring, infection, an irregular result, loss of the new breast and problems with implants.

What does it involve?

There are many ways of reconstructing the breast, which depend on factors such as how much breast tissue has been removed, what size and shape you are and your own personal preferences. If you've had a lumpectomy, insertion of a small implant to fill the gap may be most appropriate. You'll need to discuss with your surgeon what may be right for you. Breast Cancer Care has details of different methods of reconstruction and their risks.

Some of the techniques are the same as those used in cosmetic surgery, but it's usually more complex as the breast has been removed or disrupted.

The two main techniques involve:

• Inserting an implant under the skin or chest muscle
• Using a flap of tissue taken from elsewhere in your body

There has been some concern about possible health risks from breast implants, especially those made of silicone. UK experts have done an independent review of the safety of breast implants. Implants may not be suitable for some women, especially if they've lost a lot of skin during surgery.

Reconstruction using tissue flaps involves major surgery and can make large demands on a woman while the flaps are being 'developed' and moved, complete with their usual blood supply, from elsewhere on the body. But it's an option for women who have lost a lot of skin during their cancer surgery and those for whom implants aren't recommended.

It may not be suitable for women who are diabetic, heavy smokers, very overweight or who've had radiotherapy.

It's possible to reconstruct nipples on the new breast, but this is usually done later, once the breast has healed. It's cosmetic - while it may look like a nipple, it won't have any sensation or change in shape. If you'd rather not have another operation, other options include a stick-on version or a tattoo.

Don't rush into it

Before making a decision about reconstructive surgery, find out as much as you can, talk to your doctors and nurses and, if possible, talk to women who've gone through the operation themselves.

There's no rush - it can be done years after your surgery.

Adjuvant treatment

Surgery is usually followed by adjuvant treatment.

Adjuvant treatment is therapy that's given following surgery to kill any stray cells which are otherwise undetectable. Adjuvant radiotherapy may be given to the breast (after lumpectomy) or chest wall (after mastectomy) to kill cells which may be left behind after surgery. The nearby glands may also be treated.

How long the radiotherapy lasts varies, but it's normally between three and six weeks. The main side-effects are tiredness and skin soreness, but your radiotherapist (clinical oncologist) will discuss this in more detail.

Adjuvant systemic therapy is drug therapy that's given to kill off stray cells which may have escaped the breast area. There are a number of options including chemotherapy, hormone therapy or trastuzumab (herceptin) and your oncologist will discuss the most appropriate treatment regime for you.

Generally, patients with hormone receptor positive cancers will be offered some form of hormone therapy – either tamoxifen for premenpausal women or, increasingly, in postmenopausal women, one of the aromatase inhibitors (anastrazole, letrozole or exemestane).

Chemotherapy will be recommended to some patients. Herceptin may be offered to women with Her2 positive cancers who've received chemotherapy.

Again, the pros and cons and potential side-effects will be discussed in detail by your oncologist. Don’t be afraid to ask questions.

Treating secondary (metastatic) breast cancer

Where the tumour has spread beyond the breast and armpit, the treatment approach is very individualised and focused on offering therapies that will help to control the disease while minimising side-effects and improving symptoms.

Hormones, chemotherapy and herceptin may be used in various combinations. Drugs called bisphosphonates (for example, zoledronic acid) may be used to relieve the symptoms of bone secondaries and short courses of radiotherapy can be very helpful for relief of symptoms such as pain.

Clinical trials

It's quite common to be invited to enter a trial comparing one treatment approach with a newer approach to see if this improves results or reduces side-effects.

All trials are very carefully scrutinised by ethics committees to ensure they meet current best standards of care. Overall, it's felt by breast cancer specialists that they're a good thing for their patients.

It's entirely up to you whether or not you decide to enter a trial and it's important to give it careful consideration and ensure you're fully informed before you give your consent.

Survival rates

It's difficult to pronounce breast cancer cured, because secondary breast cancer can appear ten or 20 years later after tiny cells lying dormant in the liver, bones or elsewhere become active.

However, if breast cancer is going to come back it usually does so within the first two years, and after five years without disease the chances of a recurrence are very small.

With better screening and new treatments, there has been a steady improvement in survival rates for breast cancer for the past 20 years.

• Women diagnosed in the early 1970s had a 52 per cent chance of surviving for five years
• Women diagnosed between 2001 and 2003 have an 80 per cent chance

Very long-term survival has also improved. It's estimated that 64 per cent of women diagnosed in recent years will live for at least another 20 years, compared with only 44 per cent of those diagnosed in the early 1990s.

But these are overall figures and any individual's person's chance of survival depends on the type of breast cancer and their age at diagnosis.

From http://www.bbc.co.uk/health/womens_health/issues_breastcancer1.shtml